The francis report – implications for oral care of the elderly

Clinical considerations

An ageing population and its challenges

The United Kingdom has an ageing population,2 a demographic shared with other developed nations.3 Data from Scotland illustrates clearly the predicted population change from 1981 to 2031, with a notable increase in longevity and increased median age of the population4 (Figure 1).

The Francis Report

The vast report is but words on a page until a personal connection can be made to the events it describes. The transcripts describe real people who suffered terribly at the hands of the NHS. The elderly are not people ‘past their expiry date’ and cannot simply be left to ‘go off’. They have journeyed the path of life as we do now and experience the very same feelings and emotions as every other individual. Let's look at some of Robert Francis’ conclusions in the context of oral healthcare for the elderly:

The Francis Report continually exposes the reader to harrowing cases of neglect, in which poor standards of care were normalized and became accepted. The uncared for and heavily diseased mouth is regrettably a familiar sight to the dental practitioner who provides care for those older people who are dependent upon others. A case managed by one of the authors highlights such neglect:

So why do we tolerate such neglect? The scientific literature provides little reassurance that the dental profession has advanced in its care of the elderly in recent years. A snapshot of the few existing research studies undertaken in this group of patients repeatedly highlights the lack of oral healthcare for the elderly (Figure 3). The scientific evidence of poor standards of care is all too clear – we need to develop evidence-based models of care that will correct the inadequacies of current practice.

The oral pathologies affecting the older person's mouth are very familiar to dentists. Caries, particularly root caries which affects 30–60% of older people,7 periodontal disease and oral mucosal disorders are common. As awareness of oral cancer improves, it is appropriate to draw attention to the fact that 20% of oral cancers diagnosed in the United Kingdom are in those aged 75 and over.8 Unfortunately, these patients often present late, highlighting the need for regular dental examination in addition to the daily routine assistance which may be required by those unable to self-care. Supported assistance with oral hygiene presents an opportunity for carers to observe the oral mucosa and arrange for dental assessment as appropriate.

Francis was very clear in his Report that the inherent principles of patient-centred care must emerge into the foreground as the NHS moves forward. The NHS is the people's healthcare establishment, charged with providing the highest standards of care, clinical excellence and professionalism. If such high standards are set, then it is imperative that measures are taken to avoid harm across the service, including the dental profession. Oral disease has an impact on systemic health, for example in relation to aspiration pneumonia, a significant cause of death for those residing in long-term care homes.9 The mouth is the primary source of bacteria responsible for aspiration pneumonia. In the neglected mouth the bacterial load is increased and thus the reservoir of pathogenic micro-organisms is greater, increasing the risk of aspiration pneumonia.10^,11 Simple measures, such as ensuring a clean and healthy mouth for an older person, helps to protect them from harm and the dental profession needs to be leading the way.

Berwick,12 in his response to the Francis Report, gave further credence to not only the role of healthcare professionals, but also to the associated members of the NHS team from top to bottom as guardians of patient safety:

Dental healthcare professionals represent a significant component of the NHS and have an important part to play in delivering the patient-safety agenda:

Human rights embody equality. Parity is not a natural phenomenon and thus the fundamental rights which we take for granted are not omnipresent in our society. To date, care of the elderly, including oral healthcare, has not been delivered in an equitable manner and it is timely to remind ourselves of some key articles of The United Nations Convention of Human Rights. Each has relevance to care of the elderly:

The frequency with which degrading treatment was observed in the Francis Report is both unnerving and inexcusable. Those who put their trust in the care of the NHS were let down. One of the transcripts produced as evidence in the Report highlights the importance of caring for the mouth and how the most basic of caring principles, when lost, can be devastating to those who are vulnerable and dependent upon others for care:

It is prudent to reflect that Mid-Staffordshire Hospital does not stand alone in its neglect of care. In February 2007, an 87-year-old lady called Mrs McGaw died in a Scottish hospital following her admission from a care home after becoming acutely unwell. Her general medical practitioner acknowledged that the lady's condition was deteriorating and suspected an oral cause. An inquiry was established to investigate the death of Mrs McGaw. Her primary cause of death was reported as ischaemic heart disease but her oral condition raised serious concerns. It is believed that her denture might have been left in her mouth for a period in excess of two weeks and a body of opinion from the medical witnesses believed it quite likely that the denture contributed to Mrs McGaw's death.

The NHS is arguably the United Kingdom's greatest achievement as a public service and is a source of much pride to the nation's people. However, of late it has been subjected to sequential negative stories. The NHS is quoted as ‘belonging to the people’, which includes the elderly. We need to take responsibility for removing the barriers currently inhibiting their access to the care they require, which for dentistry includes mobility and access to dental premises, communication issues, dental anxiety and cost.

Undoubtedly, oral health has an impact on both general health and well-being. Older people report oral health as important to their own quality of life for the purposes of eating, being comfortable, their appearance, ability to smile and laugh and as part of their personality.13 Although people can cope without teeth and/or prostheses, their quality of life is ultimately impaired. It has a negative impact on nutrition resulting from impaired masticatory function and avoidance of foods that are hard to chew, leading to the intake of processed, high cholesterol and lipid-based foodstuffs.14

Perhaps some of the most treasured moments for those older people resident in care are when they are visited by family members. Time spent interacting with friends at social events and eating together reinforces the importance of a healthy mouth to allow the social interaction enjoyed in life.

What next?

National initiatives such as the Caring for Smiles (http://www.nes.scot.nhs.uk/education-and-training/by-discipline/dentistry/areas-of-education/oral-health-improvement-caring-for-smiles.aspx) Government initiative in Scotland, working closely with the Care Inspectorate, dementia consultants and social services, perhaps point the way towards models of improvement for the future. They need to be supported, however, with research programmes that will help us to understand and overcome the existing psychological barriers to change, if we are to witness significant improvements to oral healthcare of vulnerable older people throughout the United Kingdom. Above all, we need to remember the importance of putting the elderly patient at the very centre of the care we deliver – if we get that right, the rest will follow.